Risk Factors for Acute Hepatitis A Infection in Korea in 2007 and 2009: A Case-Control Study

This study aimed to identify the risk factors associated with acute hepatitis A virus (HAV) infection in the Korean population. Participants were recruited from five referral hospitals across the country in 2007 and from 11 hospitals in 2009. Patients with positive anti-HAV IgM antibody tests became the case group, while patients treated for non-contagious diseases at the same hospitals were recruited as controls. A total of 222 and 548 case-control pairs were studied in the 2007 and 2009 surveys, respectively. Data from the surveys were analyzed jointly. In a multivariate analysis, sharing the household with HAV-infected family members (OR, 6.32; 95% CI, 1.4-29.6), contact with other HAV-infected individuals (OR, 4.73; 95% CI, 2.4-9.4), overseas travel in 2007 (OR, 19.93; 95% CI, 2.3-174.4), consumption of raw shellfish (OR, 2.51; 95% CI, 1.8-3.5), drinking bottled water (OR, 1.64; 95% CI, 1.3-8.4), and occupation that involve handling food (OR, 3.30; 95% CI, 1.3-8.4) increased the risk of HAV infection. Avoiding contact with HAV-infected individuals and avoiding raw foods eating could help minimize the risk of hepatitis A infection. Immunization must be beneficial to individuals who handle food ingredients occupationally or travel overseas to HAV-endemic areas.

A case of variceal bleeding from the jejunum in liver cirrhosis

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.

The Use of Gabexate Mesylate and Ulinastatin for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND/AIMS: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP. METHODS: From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia. RESULTS: PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05). CONCLUSIONS: Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

A Case of Barium Appendicitis after a Small Bowel Series / 대한소화기내시경학회지

Barium appendicitis is a rare complication that occurs due to barium retention in the appendix after a barium study. It is believed that retained barium in the appendix forms a barium-coated fecalith and causes barium appendicitis. A 19-year-old man visited the hospital due to melena. He underwent an endoscopy and a colonoscopy but no bleeding focus was discovered. Next, a small bowel series was performed to confirm the absence of small bowel bleeding. Two weeks later, he felt right lower quadrant pain in his abdomen and developed a fever. A blood test revealed an elevated white blood cell count. A plain abdominal radiograph indicated retained barium in the appendix. A computed tomography scan revealed a dilated barium filled appendix. Thus, the pain was thought to caused by barium retention in the appendix that precipitated acute appendicitis. He underwent an appendectomy and healed well without complications.

Clinical Differences According to Genotype in Acute Viral Hepatitis A in Daejeon, Korea / 대한내과학회지

BACKGROUND/AIMS: Acute viral hepatitis A is a major health problem in Korea and the influx of genotype IIIA is thought to be one reason. We examined the differences in the clinical characteristics and laboratory findings of genotypes IA and IIIA in Daejeon. METHODS: From November 2009 to June 2010, 81 patients positive for IgM anti-HAV were enrolled prospectively. The hepatitis A was genotyped using real-time polymerase chain reaction. The clinical characteristics and laboratory results were compared on the basis of genotype. RESULTS: The mean patient age was 32.6 +/- 7.4 years. The mean hospitalization was 7.7 +/- 2.4 days. The patient occupation varied. Clinically, vomiting and diarrhea were relatively more prevalent in genotype IIIA than in IA. Abdominal pain and skin spots were relatively more prevalent in genotype IA than in IIIA. The hemoglobin, peak aspartate aminotransferase (AST) level, and C-reactive protein were statistically higher in genotype IIIA than in IA. The distributions of the peak AST, alanine aminotransferase (ALT) and total bilirubin values tended to be perched in genotype IIIA than in IA. The international normalized ratio (INR) tended to be slightly prolonged in genotype IIIA than in IA. CONCLUSIONS: Recently, genotype IIIA of acute viral hepatitis A has become prevalent in Daejeon. Hepatitis A genotype IIIA probably causes worse laboratory abnormalities than genotype IA.

Efficacy of Initial Treatment with Clevudine in Naive Patients with Chronic Hepatitis B

BACKGROUND/AIMS: Clevudine, a pyrimidine nucleoside analogue, has potent antiviral effects in patients with chronic viral hepatitis B (CHB). We report the efficacy of initial treatment with clevudine in naive patients with CHB living in Daejeon and Chungcheong Province, South Korea. METHODS: One hundred five adults with CHB were administered 30 mg of clevudine per day for an average of 51 weeks. We evaluated viral markers and liver biochemistry retrospectively every 3 months. RESULTS: Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and hepatitis B virus (HBV) DNA before the treatment were 184 +/- 188 IU/L, 150 +/- 138 IU/L, and 7.1 +/- 1.2 log copies/mL, respectively. Undetectable rates (< 60 IU/mL) of DNA were 36.2%, 68.9%, 83.6%, 76.2%, and 75.8% at 12, 24, 36, 48, and 60 weeks, respectively. Seroconversion rates were 9.1%, 13.6%, 24.6%, 26.5%, and 26.1% and ALT normalization rates were 64.5%, 78.1%, 87.9%, 90.0% at 12, 24, 36, and 48 weeks, respectively. Six patients (5.7%) had a viral breakthrough. CONCLUSIONS: Clevudine is a useful drug in the initial treatment of patients with CHB, with a potent antiviral effect and low incidence of viral breakthrough.

The role of flexible sigmoidoscopy in the diagnosis of Clostridium difficile-associated diarrhea / 대한내과학회지

BACKGROUND/AIMS: Clostridium difficile is an important cause of diarrhea in hospitalized patients. C. difficile-associated diarrhea (CDAD) is usually diagnosed following a stool test for C. difficile cytotoxin or stool culture for the presence of toxigenic C. difficile. However, the reported sensitivities of these tests are variable. Sigmoidoscopy may be an effective diagnostic method in patients with a false-negative stool test for cytotoxin. This study examined the role of flexible sigmoidoscopy in the diagnosis of CDAD. METHODS: Among the patients who had diarrhea and were examined with sigmoidoscopy in Eulji University Hospital between January 2005 and July 2008, 102 patients suspected of having antibiotic-associated diarrhea (AAD) based on their clinical symptoms were enrolled. Of the 102 patients, 74 were diagnosed with CDAD based on C. difficile cytotoxin or sigmoidoscopic findings of pseudomembranous colitis. The medical records of these 74 patients were reviewed retrospectively. RESULTS: Of the 74 patients, sigmoidoscopic findings revealed a pseudomembrane in 63 patients (85.1%) and colitis in nine (12.2%), while two patients (2.7%) appeared normal. Of the 63 patients with pseudomembranous colitis at sigmoidoscopy, the stool C. difficile cytotoxin assay was negative in 27 (42.9%). CONCLUSIONS: Flexible sigmoidoscopy was highly sensitive in pseudomembranous colitis and is useful in diagnosing patients with a delayed or negative stool test for C. difficile cytotoxin. Therefore, we recommend flexible sigmoidoscopy in patients suspected of having C. difficile-associated diarrhea for the diagnosis of CDAD.

A Case of Phlegmonous Gastritis Associated with Marked Gastric Distension

Phlegmonous gastritis is an acute and severe infectious disease that is occasionally fatal if the diagnosis is delayed. Alcohol consumption, an immunocompromised state (e.g., due to HIV infection, rheumatoid arthritis, diabetes mellitus, or adult T-cell lymphoma), and mucosal injury of the stomach are reported to be predisposing factors. The main treatments for phlegmonous gastritis are antibiotics administration or surgery. In this case, the patient's stomach was markedly distended due to long-lasting gastric-outlet obstruction, which is thought to be the predisposing factor for phlegmonous gastritis. We inserted a metal stent at the obstructed site palliatively due to strong refusal by the patient for surgery. The patient recovered after stenting and antibiotic therapy.

A Case of Chronic Lymphocytic Leukemia Involvement of the Terminal Ileum and Colon That Was Seen on Colonscopy as a Form of Lymphoid Hyperplasia / 대한소화기내시경학회지

Follicular lymphoid hyperplasia is commonly seen when performing pediatric endoscopy. But in adults, these findings can imply an underlying gastrointestinal or systemic illness, besides the normal variant. On the other hand, colonic involvement of chronic lymphocytic leukemia (CLL) is seen in about 5% to 20% of autopsy cases. However, there have been few reports on the colonoscopic appearance that corresponds to colonic involvement by CLL, and the reported colonoscopic appearances have included polyps, ulcers, granularity, submucosal nodules, erythema, the red ring sign etc. We report here on a case of CLL neoplastic lymphocyte involvement of the terminal ileum and colon as a form of lymphoid hyperplasia, and this was seen when performing colonoscopy.

A Case of Gastrointestinal Amyloidosis in Asymptomatic Multiple Myeloma

Amyloidosis is a disorder characterized by extracellular deposition of amyloid materials in multiple organs and tissues. Amyloidosis commonly shows a systemic involvement. Gastrointestinal involvement is common in amyloidosis and is usually asymptomatic. The gastrointestinal manifestations include gastroparesis, diarrhea, steatorrhea, constipation, intestinal pseudo-obstruction, and bleeding. The diagnosis of amyloidosis is difficult because there are absence of systemic symptoms and nonspecific endoscopic findings. Asymptomatic multiple myeloma is an asymptomatic plasma-cell proliferative disorder associated with a high risk of progression to symptomatic multiple myeloma or amyloidosis. Recently, we experienced a 60-year-old man who presented with hematochezia and weight loss as manifestations of gastrointestinal amyloidosis involving the stomach and the colon induced in asymptomatic multiple myeloma confirmed by endoscopic biopsies and bone marrow biopsy. We report a case with a review of the literature.

A Case of Gastrointestinal Amyloidosis in Asymptomatic Multiple Myeloma

Amyloidosis is a disorder characterized by extracellular deposition of amyloid materials in multiple organs and tissues. Amyloidosis commonly shows a systemic involvement. Gastrointestinal involvement is common in amyloidosis and is usually asymptomatic. The gastrointestinal manifestations include gastroparesis, diarrhea, steatorrhea, constipation, intestinal pseudo-obstruction, and bleeding. The diagnosis of amyloidosis is difficult because there are absence of systemic symptoms and nonspecific endoscopic findings. Asymptomatic multiple myeloma is an asymptomatic plasma-cell proliferative disorder associated with a high risk of progression to symptomatic multiple myeloma or amyloidosis. Recently, we experienced a 60-year-old man who presented with hematochezia and weight loss as manifestations of gastrointestinal amyloidosis involving the stomach and the colon induced in asymptomatic multiple myeloma confirmed by endoscopic biopsies and bone marrow biopsy. We report a case with a review of the literature.

A Case of Obstructive Jaundice Caused by Paradoxical Reaction during Antituberculous Chemotherapy for Abdominal Tuberculosis

Abdominal tuberculosis is not a rare disease, but obstructive jaundice caused by tuberculosis (tuberculous lymphadenitis, tuberculous enlargement of the head of pancreas, and/or tuberculous stricture of the biliary tree) is rare. We recently experienced a case of obstructive jaundice as a result of paradoxical reaction of periportal tuberculous lymphadenopathy that was treated successfully with corticosteroid and biliary drainage. No similar cases have been reported previously.

Acute Drug-Induced Hepatitis Caused by Albendazole

Albendazole binds to parasite's tubulin inhibiting its glucose absorption. Its common adverse effects are nausea, vomiting, constipation, thirst, dizziness, headache, hair loss and pruritus. Although mainly metabolized in the liver, abnormal liver function tests were a rare adverse effect during clinical trials and we found no literature about albendazole-induced hepatitis requiring admission. This patient had a previous history of albendazole ingestion in 2002 resulting in increase of liver function tests. And in 2005, the episode repeated. We evaluated the patient for viral hepatitis, alcoholic liver disease, and autoimmune hepatitis, but no other cause of hepatic injury could be found. Liver biopsy showed periportal steatosis and periportal necrosis. The initial abnormal liver function test improved only with supportive care. These findings and the Roussel Uclaf Causality Assessment Method of the Council for International Organizations of Medical Sciences (RUCAM/CIOMS) score of 9 are compatible with drug-induced hepatitis so we report the case of this patient with a review of the literature.

Clinical characteristics of colonic diverticulitis in young patients / 대한내과학회지

BACKGROUND/AIMS: Colonic diverticulitis is an uncommon disease in young patients. However, the frequency appears to have increased in Korea among young patients. The purpose of this study was to determine the diagnosis, treatment and clinical course of young patients with diverticulitis of the colon. METHODS: The hospital records of 70 patients with diverticulitis between July 1997 and April 2006 from the Eulji university hospital were reviewed. We analyzed the clinical course and outcomes of patients according to age. RESULTS: In the 36 patients below the age of 40, the male to female ratio was 2:1. Thirty four young patients had right uncomplicated colonic diverticulitis. Twenty four young patients treated with antibiotics did not require surgery or develop complications. CONCLUSION: The majority of young patients with diverticulitis were in their fourth decade of life and it was predominantly seen in males. Diverticulitis in young patients at our hospital did not appear to take a more aggressive clinical course than it did in older patients. Bowel rest and antibiotic treatment were safe and effective treatments for acute uncomplicated colonic diverticulitis in young patients.

A Case of Cameron Ulcer Associated with Massive Gastrointestinal Bleeding Treated by Angiographic Embolization

Gastric erosions or ulcers located at or near the level of the neck of a large diaphragmatic hernias are referred to as Cameron ulcers. Cameron ulcers are almost always incidental findings. In some patient, Cameron ulcers cause the dyspepsia, gastroesophageal reflux disease and iron deficiency anemia due to chronic gastrointestinal bleeding or even acute bleeding. We report the case of an acute upper gastrointestinal bleeding due to a Cameron ulcer in a patient with a history of aspirin and NSIADs use, which was successfully treated with angiographic coil embolization.

Brunnera's Gland Hyperplasia: Treatment of Severe Diffuse Nodular Hyperplasia Mimicking a Malignancy on Pancreatic-Duodenal Area

Brunnera's gland hyperplasia is a benign tumor of the duodenum and it is rarely associated with clinical symptoms. We report on a 64-yr-old man with Brunnera's gland hyperplasia who had undergone a duodenocephalo-pancreatectomy. The reason is that he presented upper gastrointestinal obstructive symptoms and the esophagogastroduodenoscopic finding revealed the lesion to be an infiltrating type mass on the second portion of the duodenum with luminal narrowing. An abdominal computed tomography showed a 2.5 cm-sized mass in the duodenal second portion with a suspicious pancreatic invasion and 7 mm-sized lymph node around the duodenum. Duodenocephalopancreatectomy was successfully performed. Histological examination revealed a Brunnera's gland hyperplasia. The final diagnosis was the coexistence of Brunnera's gland hyperplasia and pancreatic heterotopia with a pancreatic head invasion. The literature on Brunnera's gland hyperplasia is reviewed.

A Case of Pyoderma Gangrenosum Associated with Ulcerative Colitis

Ulcerative colitis is associated with various extraintestinal manifestations. Skin lesions can occur in 9-19% of patients with ulcerative colitis. Pyoderma gangrenosum is the most severe dermatologic complication that is associated with ulcerative colitis. It is a painful, chronic ulcerating skin disease of unknown cause. The lesions usually appear on the pretibial area, but may also be found elsewhere. Diagnosis is clinical as there are no accepted histological diagnostic criteria. Systemic steroid therapy remains the treatment of choice in most patients, but various other agents have been used with occasional success including topical antibiotics, cyclosporine and infliximab. We experienced a case of pyoderma gangrenosum that developed on both pretibial areas in a 41-year-old female patient with active ulcerative colitis. The patient was treated with a corticosteroid and sulfasalazine. We report this case with a review of the literature.

Clinical feature of Fitz-Hugh-Curtis syndrome: Analysis of 25 cases / 대한간학회지

BACKGROUND/AIMS: Fitz-Hugh-Curtis syndrome is defined as perihepatitis associated with pelvic inflammatory disease (PID). We retrospectively analyzed clinical and laboratory manifestations as well as the therapeutic response in patients with clinically diagnosed Fitz-Hugh-Curtis syndrome. METHODS: A cohort of 25 patients with PID and perihepatitis (as diagnosed by dynamic abdominal computed tomography (CT)) was enrolled. The prognosis, clinical manifestations, and physical examination, laboratory, and CT findings were analyzed. RESULTS: The mean (+/-SD) age of the patients was 32(+/-8) years, and all of them were sexually active, premenopausal women, and presented with abdominal pain. Of these, 52% complained of vaginal discharge. On physical examination, right upper-quadrant tenderness was the most common finding (84%), with lower-abdominal tenderness being present in 20% of patients. On laboratory examination, erythrocyte sedimentation rate and C-reactive protein were increased in 76% and 92% of the patients, respectively. The white blood cell count was increased in 60% of them. Most patients had a normal liver function test. Using a specimen of the cervical discharge, the polymerase chain reaction to test for Chlamydia trachomatis were positive in 87% (13/15) of the patients, and Chlamydia antigen was found in 75% (9/12) of them. Dynamic abdominal CT revealed subcapsular enhancement of the liver in the arterial phase. All of the patients improved with antibiotic therapy. CONCLUSIONS: Symptoms and physical findings suggestive of PID are not present in many patients with Fitz-Hugh-Curtis syndrome. When a premenopausal woman complains of upper abdominal pain and shows CT findings compatible with perihepatitis, examination of cervical discharge would be recommended to assess the possibility of Fitz-Hugh-Curtis syndrome.

Two Cases of Rectal Dieulafoy's Lesion with Massive Hematochezia in Elderly Patients

Dieulafoy's lesion is rare cause of massive gastrointestinal bleeding. Dieulafoy's lesion is understood to represent a tiny submucosal defect with fibrinoid necrosis at its base, overlying a large, tortous, thick-walled artery in the muscularis mucosa. Although the original descriptions and early reports were of lesions in the proximal stomach, similar lesions have subsequently been reported in the esophagus, duodenum, jejunum, colon and rectum. Rectal Dieulafoy's lesion is rare but it is one of the causes of massive hematochezia. We report two cases of rectal Dieulafoy's lesion that was successfully treated with endoscopic hemostasis by clipping in the elderly patients.

Esophageal Thermal Injury by Hot Adlay Tea

Reversible thermal injury to the esophagus as the result of drinking hot liquids has been reported to generate alternating white and red linear mucosal bands, somewhat reminiscent of a candy cane. This phenomenon is associated with chest pain, dysphagia, odynophagia, and epigastric pain. Here, we report a case of thermal injury to the esophageal and oral cavity due to the drinking of hot tea, including odynophagia and dysphagia. A 69-year-old man was referred due to a difficulty in swallowing which had begun a week prior to referral. The patient, at the time of admission, was unable to swallow even liquids. He had recently suffered from hiccups, and had consumed five cups of hot adlay tea one week prior to admission, as a folk remedy for the hiccups. Upon physical examination, the patient's oral cavity evidenced mucosal erosion, hyperemia, and mucosa covered by a whitish pseudomembrane. Nonspecific findings were detected on the laboratory and radiological exams. Upper endoscopy revealed diffuse hyperemia, and erosions with thick and whitish pseudomembraneous mucosa on the entire esophagus. The stomach and duodenum appeared normal. We diagnosed the patient with thermal esophageal injury inflicted by the hot tea. He was treated with pantoprazole, 40 mg/day, for 14 days, and evidenced significant clinical and endoscopic improvement.